Client has a pacemaker, history of
CHF and ARF, and her labs showed her WBC count @ 30,000.

She coded at 4am

Objective

RP’s vitals were pulse 80, BP 81/40, and her temperature was 95.3. She had a gallbladder
drain and was on the ventilator. She had sluggish reactive pupils, bilateral rhoncci,
abdominal distention, and no edema. Her skin was cool, dry, pale.

Problem

Fluid volume
deficient

Long Term:

Client will be able to describe symptoms
of fluid loss and certain measures that can be taken to treat or prevent fluid volume
loss following hospital stay.

-Watch for early
signs of hypovolemia, including restlessness, weakness, muscle cramps, headaches,
inability to concentrate, and postural hypotension.

Rationale: A
study of healthy volunteers restricted their fluid for up to 37 hours and reported
symptoms of headache, decreased alertness, and inability to concentrate (Shirreffs,
2004).

Client stated that headaches, restlessness,
and inability to concentrate are signs of hypovolemia and that she should contact
her health care provider if this happens. Client will also increase her fluid intake.